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Doctors Should not be Treating Physician Assistants as Substitutes

August 26, 2020

People visiting a walk-in clinic or family health team office may be seen by someone with a stethoscope around their neck, who they will likely assume is a doctor. That is a dangerous assumption to make, as there is a good chance that person is a physician assistant (PA).

Since 2007, PAs have been allowed to work in Ontario and they are also found in Manitoba, Alberta, Nova Scotia and New Brunswick. According to the Canadian Association of Physician Assistants (CAPA) website, there are now 650 PAs practising in Canada with more than 400 in Ontario.

So, what is a PA? According to CAPA, they are “highly skilled health professionals who support physicians in all health care settings … the PA is a physician extender and not an independent practitioner; they work under the direction of supervising physicians within the client/patient-centered care team.”

That sounds straightforward and many medical offices have welcomed them, as their duties include conducting patient interviews and completing medical histories, a time-consuming part of medical care.

What is more troubling is that some physicians seem to regard PAs as substitutes, delegating work to them that is well above their skill level. Keep in mind they are accredited after just two years of study, compared to the decade of hitting the books and practical training required for a physician.

I think part of the reasons why some MDs have this erroneous idea about a PA’s role is that some provincial governments partially fund their first placement. Here in Ontario, the Physician Assistant Career Start Grant Program helps graduates from two PA programs find work.

“Employment settings are various and include, but are not limited to, emergency departments, primary care and internal medicine,” the program’s literature reads.

Perhaps some physicians incorrectly view this government funding as an endorsement of a PAs ability. Those MDs should review the Delegation of Controlled Acts statement put out by the College of Physicians and Surgeons of Ontario. It states, “certain acts, referred to as ‘controlled acts,’ may only be performed by authorized health-care professionals. However, under appropriate circumstances, these acts may be delegated to others [resulting] in more timely delivery of health care.”

The statement makes it clear that in “every instance of delegation, the primary consideration must be the best interests of the patient … controlled acts must not be delegated solely for monetary or convenience reasons.”

Ontario’s Regulated Health Professions Act (RHPA) governs the actions of the 26 medical professions but PAs are not there. They are totally unregulated and not subject to the high standards of interprofessional practice demanded by the Act. If a physician allows a PA to perform a procedure beyond the range of delegable services, and there is a negligence claim, I think there may be a chance that physician would not be covered by the Canadian Medical Protective Association, which has been providing liability coverage and legal support to physicians since 1901.

Granted, doctors are allowed to delegate certain tasks, such as giving vaccinations, EKGs or measuring vital signs. The ethical and legal use of a PA would include:

  • Reviewing the patient’s history and recording it.
  • Taking blood pressure, temperature and all vitals including height and weight.
  • Recording all delegated tasks carried out on the physician’s instructions.
  • Recording the physician’s examination, the physician’s treatment plan and advice to the patient, and ensuring the record is signed off by the physician at the end of each shift.
  • Laboratory testing and diagnostic imaging can be implemented by the PA if so instructed by the supervising physician.

The PA cannot:

  • Commence a patient encounter if the physician is not on site
  • Implement or sign off on a prescription or renewal.
  • Give a patient a diagnosis or outline a treatment plan unless instructed by the supervising physician.
  • The PA may not exam any part of the body where the disrobing of the patient is required.
  • The PA may never perform an examination of a gender-sensitive nature (i.e., pap smears, breast exams, rectal exams, etc.) and may not perform any invasive procedure of any kind.

Let’s use the example of someone who comes to a clinic with cold symptoms. A doctor could direct the PA to do a minor examination of the person’s head and neck and write down what they see. The physician should then confirm the information then dictate to the PA what the diagnosis and subsequent treatment will be, and if any prescription drugs are needed.

That is how it is supposed to work. But in some medical settings, patients only see the PA, who makes a diagnosis and writes a prescription then dismisses the patient, without any doctor involvement.

A physician who allows that to happen is definitely violating the RHPA, especially if they consequently bill OHIP for the visit. To do so is illegal and unethical and contravenes the regulatory requirements for doctors. It also disregards OHIP billing rules, as only a physician can charge OHIP for services the physician either renders or delegates under direct supervision.

Billing is a privilege given to physicians, basically allowing them to write their own paycheque on the taxpayers’ bank account. Other medical professionals – psychologists, nurse practitioners, dentists, etc. – can’t directly bill, so why are some doctors abusing this privilege by billing for work done by PAs without their supervision or for services only performed by doctors?

As a health law lawyer, I’m very concerned to see instances where PAs are being asked to do work they should not be doing. Medical Regulators share this concern as do patients, who sometimes only see PAs when they visit medical offices.

If a physician hires a PA and they are doing services beyond the limited range of services the Regulator permits a delegate to perform under the direct supervision of a physician, that MD is violating the standards of professional practice. They are also potentially defrauding the government if they permit a bill to be forwarded to OHIP for services not directly performed by the physician under direct supervision.

This situation should not continue. I agree that PAs have a place in our health-care system, but that role is to assist doctors, not do their work and run their practices. Utilized appropriately ethically and legally, PAs can be a valuable asset in the running of a physician’s practice, facilitating access to the timely care of a physician.

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